Author: Cara Williams
Refractory migraine is a type of migraine that does not respond to typical migraine treatments. People with refractory migraine can experience an aura with a severe headache.
Migraine is a neurological condition involving severe headaches and other symptoms that can affect a person’s day-to-day life. It is a leading cause of disability in the United States, and research estimates that it affects 20% of females and 10% of males.
There are many options for the treatment of migraine. For some people, standard treatment may not bring relief. Doctors refer to these cases as refractory migraine. Research from 2017 estimates that refractory chronic migraine affects around 4% of the population.
This article discusses refractory migraine, including the definition, symptoms, and treatment options.
Some definitions of refractory migraine only include chronic migraine. However, the American Headache Society uses a definition of refractory migraine that also includes medication overuse migraine and episodic migraine.
Most definitions consider headache conditions as refractory migraine after two-four unsuccessful rounds of treatment.
Migraine episodes can vary and may have several stages, including:
Symptoms that can occur in the prodrome stage include:
- mood changes
- difficulty focusing
- food cravings
- frequent urination
- sensitivity to light and sound
Aura may occur in some people just before an episode. Aura can include flashing lights and other sensory symptoms.
During the headache phase, a person can experience head pain that:
- is moderate to severe, possibly preventing them from completing their daily activities
- feels like a throbbing or pounding
- occurs on one or both sides of the head
- affects the area around the eyes or cheeks
- worsens with physical activity
A person may also experience gastrointestinal symptoms, such as nausea and vomiting.
Research from 2016 estimates that around 80% of people experience a postdrome phase. This phase lasts for a day or two after the headache. The most common symptoms of this phase include:
- difficulty concentrating
- neck stiffness
Some people experience aura immediately before the headache stage of a migraine. Aura symptoms usually start gradually over a few minutes and last for up to an hour or even longer.
During aura, a person can experience neurological symptoms such as:
- sensory changes
- vision changes
- speech problems
- motor symptoms, such as muscle weakness and difficulty balancing
The most common aura symptoms are visual disturbances, which can involve:
- seeing zig-zag lines, spots, or squiggles
- experiencing blind spots or total vision loss
- having distorted vision, such as blurred vision or a loss of color vision
Aura symptoms may continue throughout the headache stage or even occur without a headache.
The exact difference between migraine with and without aura is not fully understood. However, some evidence suggests that migraine with aura may respond differently to some treatments.
Getting a diagnosis is important, as it helps people understand their symptoms and seek treatment.
There is no specific test to diagnose migraine. A doctor will ask questions about the nature of a person’s symptoms and medical history. They may also perform a neurological exam. The doctor may also order further tests, such as MRI and CT scans, to help rule out other potential causes of the symptoms.
The doctor can then decide if the person’s symptoms fit the criteria for migraine.
The International Headache Society (IHS) defines migraine as having two out of four of the following features:
- pain on one side of the head
- a pulsating, throbbing feeling
- moderate-to-severe intensity
- pain that worsens with physical activity
The criteria also include having at least five headaches lasting 4–72 hours and experiencing either nausea and vomiting or sensitivity to light or sound.
The IHS considers a person’s migraine chronic if they experience headaches on 15 or more days per month for 3 months.
If a person’s migraine episodes do not respond to treatment, a doctor may consider their condition to be refractory migraine.
Standard treatments for migraine involve medications to reduce pain, such as nonsteroidal anti-inflammatory drugs.
A doctor may also develop a treatment plan to prevent migraine episodes with medications, such as blood pressure medications, antidepressants, or anticonvulsants.
Treatment may also involve antiemetics, which can help manage nausea and vomiting.
Some other medications that a doctor could consider for the treatment of refractory migraine include:
- Dihydroergotamine (DHE): DHE comes in several forms, including a nasal spray, oral pills, and an IV injection.
- IV magnesium sulfate: This treatment is suitable for migraine with aura.
- Corticosteroids: A doctor may administer this treatment through an IV line or give it as an oral pill.
- Anti calcitonin gene-related peptides (CGRP): A doctor administers these treatments as injections under the skin, with the exception of eptinezumab, which involves an IV infusion.
- Neuromodulation: This treatment involves a handheld or implanted device that can regulate activity in the nervous system that contributes to migraine. There are currently four devices with Food and Drug Administration (FDA) approval that target different areas to treat migraine episodes.
- Oral preventive CGRP medications: A doctor may prescribe oral medications such as Qulipta or Nurtec to treat episodic migraine.
Refractory migraine can be difficult to treat. However, condition awareness and lifestyle changes may help a person reduce the severity of their migraine episodes.
There may be certain triggers that exacerbate a person’s symptoms. Some lifestyle changes that can help a person avoid potential triggers and manage their migraine headaches include:
- Sleeping well: Good sleep hygiene may help reduce the severity and frequency of migraine episodes.
- Exercising regularly: Getting regular exercise may help with migraine. A person can start by trying a small amount and then building up over time. If exercise seems to be a migraine trigger, people can discuss how to work around this with a doctor.
- Eating regular meals: Hunger can be a migraine trigger for some people. People should aim to eat regular, balanced meals spaced throughout the day.
- Keeping a food diary: A person can use a diary to keep track of their migraine frequency and severity to identify any possible triggers. Common foods and drinks that can trigger migraine episodes include chocolate, caffeine, and alcoholic drinks.
- Managing stress: A person can try to manage their stress by undergoing cognitive behavioral therapy or learning mindfulness and relaxation techniques.
Refractory migraine typically responds poorly to common migraine treatments.
Refractory migraine can affect a person’s day-to-day life and be challenging to manage. However, there are many treatment options and lifestyle changes that a person can try to help manage their symptoms.